Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

Andrawis,, Mary; Ellison, L T C, Christopher; Riddle,, Steve; Mahan, Kurt, (Charles); Collins, Curtis, D; Brummond,, Philip; Carmichael,, Jannet

doi:10.1093/ajhp/zxz069

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

Andrawis,, Mary;Ellison, L T C, Christopher;Riddle,, Steve;Mahan, Kurt, (Charles);Collins, Curtis, D;Brummond,, Philip;Carmichael,, Jannet 2019-06-03 00:00:00 Abstract Purpose Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. Summary The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. Conclusion An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided. accountability, dashboard, medication quality, metrics, pharmacist value, quality measures, value KEY POINTS As the healthcare landscape continues to shift from fee-for-service reimbursement to value-based purchasing, pharmacists have an opportunity to demonstrate value as a member of the care team. Quality measures assist in the evaluation of healthcare processes, outcomes, patient experience of care, and organizational structure that are attributable to a provider or facility. This article outlines a framework and makes recommendations for health-system pharmacists and pharmacy departments to identify important measures to benchmark and, ultimately, improve upon their performance. In 2014, ASHP convened the Pharmacy Accountability Measures (PAM) Work Group to identify quality measures that demonstrate the value of health-system pharmacists in improving patient safety and health outcomes.1 Since then, the healthcare landscape has continued transitioning toward improving quality, safety, and efficiency. Pressures from a number of fronts are rapidly driving changes to reduce variability, improve quality and safety, and decrease costs in care delivery. Sweeping changes spurred by the Patient Protection and Affordable Care Act of 2010 and Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 impact health systems and signify certainty in the shift towards value-based payment for healthcare. For health systems, there are 3 prominent Centers for Medicare and Medicaid Services (CMS) value-based programs designed to link performance to payment in the hospital setting: the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Conditions Reduction Program.2 The Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program went into effect in 2012, while the Hospital-Acquired Conditions Reduction Program went into effect in 2014. These programs provide Medicare payment incentives for positive outcomes and/or withhold payments to penalize negative outcomes. For outpatient providers, MACRA authorized the Quality Payment Program to make Medicare payments based on value instead of volume. The Merit-Based Incentive Payment System provides performance-based payment adjustments to providers; participation in Alternative Payment Models also provides incentive payments. In addition to these CMS value-based payment programs there is pressure from other stakeholders and payers to reimburse for value. In this environment, health systems must create new efficiencies by redesigning patient care models, using high-value supplies, outsourcing services, and considering performance-based contracts with vendors and employees.3 Accountability As previous recommendations from the PAM Work Group were published, the Department of Health and Human Services (HHS) released the National Action Plan for Adverse Drug Event (ADE) Prevention.4 The National Action Plan was initiated in response to a bipartisan letter from the U.S. Senate urging action to address ADEs regarding recent literature describing hospitalizations attributable to common medications or medication classes.5,6 In short order, HHS convened a federal interagency steering committee, and the resulting publication identified 3 high-impact medication classes: opioids, anticoagulants, and diabetes agents.4 This publication has garnered national attention and highlighted urgency for accountability in safe medication use. Team-based care models and health-system continuity between inpatient and outpatient settings allow the health-system pharmacist to be an equal contributor to patient care. The increasing focus on value in healthcare provides a unique opportunity for the pharmacy profession not only to participate on the care team but also to actively accept and assert accountability for medication-related and overall patient outcomes.7 Pharmacists can and should assume leadership roles across their respective organizations by engaging all relevant stakeholders to implement improvements that advance organizational performance, particularly for medication-related care. While there is evidence demonstrating pharmacist contributions in improving clinical outcomes and decreasing cost of care, the programs and interventions described tend to be developed locally and often lack universal applicability.8,9 No consolidated list of quality measures that clearly identifies activities or outcomes for which pharmacists should be responsible or accountable exists. The goal of the previous work group was to identify a suite of measures that address preventable harm and improve patient outcomes in the inpatient and outpatient settings that could be adopted universally on pharmacy departmental and organizational dashboards to reflect and demonstrate accountability. The goals of the current project revision remain consistent with the previous effort. The focus of the current PAM Work Group is to identify a revised suite of measures that globally address safety and quality in the inpatient and outpatient settings and during transitions of care. First, the work group identified quality measures that are most important for pharmacists within healthcare organizations to assume accountability for and demonstrate the value of pharmacist services. Second, by concentrating emphasis on the most important measures, pharmacy departments will have a more positive impact by improving performance of the identified measures. Third, by demonstrating improved performance on measures with patients, physicians, nurses, and other healthcare professionals, the pharmacy profession raises awareness of its value to patient care and the healthcare system. Quality measures overview Measuring performance of care intends to optimize the quality, safety, effectiveness, and efficiency of the care provided.10,11 Without measuring performance on standardized measures, quality and safety of care cannot be assessed, nor can the level of care be compared between healthcare systems. In general, quality measures have demonstrated improvements in care and allowed incentivized payment systems to evolve to reward higher-performing systems while withholding payments for lower-performing systems. For instance, National Quality Forum (NQF)–endorsed measures are purported to have saved nearly $30 billion to the healthcare system and to have reduced surgical infection rates by 16%, patient harm by 21%, and early elective C-section deliveries by 89%.12 CMS currently contracts with NQF as an independent third party to assess quality measures developed by measure stewards to determine if they should be endorsed as measures for federal and commercial reporting programs. NQF has a refined endorsement process including a rigorous criteria-based review by a committee of experts representing multiple industry stakeholders using its Consensus Development Process.13 Examples of measure stewards include CMS, the Centers for Disease Control and Prevention (CDC), American Heart Association, American College of Cardiology, and Pharmacy Quality Alliance (PQA), to name a few. Typically, measures must have significant evidence in primary studies and Cochrane and systematic reviews and be supported by national guidelines with data demonstrating significant reductions in morbidity and/or mortality. In addition, the NQF Measure Applications Partnership guides HHS on its selection of quality measures across more than 20 federal public reporting programs.14 Project description Beginning in 2018, the PAM Work Group initiated efforts to review and update the inaugural suite of pharmacy accountability measures that were published in 2014. In this update, the work group reviewed and expanded the clinical topic areas, considered previous and new measures for inclusion within each area, added measures for transitions of care within each area, and tested a methodology for ongoing and continuous updates to the PAM. Relevance In many healthcare settings, quality measures are a common focus for medical, hospital, pharmacy, and nursing staff; however, measure compliance is typically managed and addressed by quality and safety personnel. Historically, manual processes have been used to collect and analyze clinical data or ensure accuracy of claims-based measures. With the transition to electronic health records (EHRs), much data necessary for tracking quality measures is available in the form of readily retrievable clinical data fields that are becoming increasingly more standardized with the development and implementation of interoperability standards. This process will continue to evolve, making clinical data retrieval more efficient and standardized. Indeed, standardization of quality measure numerators and denominators for electronic retrieval can allow comparison across health systems.15 As the pharmacy profession has evolved to a more cognitive and clinical care role, with a shift towards decentralized services in acute and ambulatory care settings, pharmacists and pharmacy departments are uniquely positioned within health systems to more visibly take accountability for quality measures and have a positive impact on performance. While pharmacy personnel are a relatively small labor pool compared with others, interaction with nursing personnel, physicians, other advanced practice clinicians, and patients is common, and pharmacists have many tools available to assess patients and document outcomes within the EHR. This unique positioning allows pharmacists to assess patients, implement manual or electronic clinical decision support, review complex drug therapies, collaborate to implement therapeutic plans, and change the health system’s performance. In addition, pharmacists often have a scope of practice that may allow direct implementation of a new therapeutic plan allowing improved documentation in the EHR. Numerous studies and systematic reviews have demonstrated a positive impact on performance of quality measures with inclusion of pharmacists as part of the care team.9 Raising awareness of which measures are most important and which measures pharmacy is best positioned to significantly impact may increase pharmacy profession accountability to improve healthcare outcomes. The portfolio of measures is constantly changing, with measures being added, assessed for continuation (maintained), or retired. The PAM Work Group project assists with identifying the most important measures in order to simplify the pharmacy profession’s prioritization efforts. Thus, the relevance of this project is broad, given pharmacists’ unique positioning and demonstrated ability to positively impact quality, efficiency, and safety within health systems. Often driven by population health strategies and efforts to reduce readmissions and manage length of stay, the need to reduce unwarranted variation in clinical care and improve patient outcomes by managing transitions of care between settings along the care continuum continues to be a top priority. Therefore, the transition-of-care setting was added to the previous inpatient and outpatient categories for this review. Pharmacists are uniquely trained and positioned to improve care transitions by effectively communicating with the patient and the appropriate members of the healthcare team. Process for identifying measures A survey of available healthcare quality repositories revealed tremendous expansion in the area of quality measures since the initial PAM work. The group decided to consider the entire database of National Quality Measure Clearinghouse (NQMC) measures and the NQF-endorsed measures, accessible through the NQF Quality Positioning System (QPS), as sole sources for potential PAM candidates.16,17 NQMC is a database of specific evidence-based healthcare quality measures that rely on the submitter to provide substantive evidence of the reliability and validity of the proposed measure or demonstrate that the measure has been vetted by another organization that promotes rigorous development and use of measurement in healthcare (e.g., NQF).16 The NQF QPS is a measure search tool that allows queries based on measure type, endorsement status, measure steward, use in federal program, clinical condition/topic area, care setting, National Quality Strategy priority, actual/planned use, data source, level of analysis, and target population.17 Due to reductions in the NQMC budgetary appropriation, database updates after July 2018 have been limited to CMS-developed measures; therefore, the PAM Work Group decided to exclusively access NQF-endorsed measures archived in the QPS when considering measures for inclusion. The 4 screening criteria used to determine if a measure was “pharmacy related” were that the measure (1) was predominately medication related, (2) involved monitoring directly associated with medication therapy, (3) involved monitoring directly related to a clinical domain of interest, or (4) targeted common interventions associated with pharmacy practice (e.g., correcting errors of omission of drug therapy, optimizing drug selection and dosing, reducing the risk of an ADE). If any of the criteria were satisfied, the measure was included in the initial measure set for review. A single reviewer examined all medication-related and pharmacy-sensitive endorsed measures from the NQF QPS (n = 656) and classified them into the original PAM Work Group clinical domains (anticoagulant safety, glycemic control, antimicrobial stewardship, and pain management). However, the results of the measure screening and classification showed a significant number of measures were in categories that fell outside of the original PAM clinical domains. With further consideration, 4 potential new domains were identified for the group to consider: (1) behavioral health, (2) comprehensive medication review, (3) polypharmacy, and (4) pharmacy/medication systems. The work group decided it was valuable to adequately address emerging clinical and therapeutic areas of importance while continuing to consider measures tied to national strategies for improving health. The consensus was to include the 3 original PAM clinical domains in concert with the 3 initial targets of the National Action Plan for ADE Prevention (anticoagulants, hypoglycemics, and opioids), continue the antimicrobial stewardship domain (also now tied to a National Action Plan for Combating Antibiotic-resistant Bacteria), and include 2 new clinical domains, behavioral health and cardiovascular control.4,18 Once measures were divided into the selected domains, 140 measures remained. Figure 1 depicts the process for identifying and reviewing the selected measures. Figure 1. Open in new tabDownload slide Process for selecting pharmacy accountability measures. Figure 1. Open in new tabDownload slide Process for selecting pharmacy accountability measures. Measures endorsed by NQF have met robust criteria of importance, scientific acceptability, feasibility, validity, and usability and use. Those conditions are met during the measure development and endorsement process; however, healthcare leaders need an approach to identify the measures and outcomes that matter most to their organization. Previously, Chassin et al.10 and Baker and Chassin11 outlined criteria for considering accountability measures that evaluate processes and outcomes of care, respectively. For the purpose of this effort, the PAM Work Group referenced those criteria and modified feasibility criteria for evaluation of pharmacy-sensitive process and outcome measures, as follows: There is strong evidence that the metric improvement leads to better outcomes. The measure accurately captures whether evidence-based care has been provided. Data for the measure are readily available and retrievable without undue burden. Implementing the measure has little or no chance of inducing unintended consequences. Improvement of the measure is understandable, useful, and meaningful to stakeholders (e.g., patients, providers, payers). After initial measure refinement, the subsets were sent to SMEs for final measure selection. Each SME panel was asked to rank measures according to the 5 feasibility criteria, using a Likert-type scale; the measures receiving the highest scores were retained for public comment. The SME panels were composed of pharmacists with notable clinical experience and training around the respective clinical domains of the measure sets. These panels determined the relevance of the measures to pharmacy practice and the level of accountability, stratified the measures according to the above feasibility criteria, and selected the best measures for each care setting (inpatient, outpatient, and transition, respectively). Lastly, the selected measures, organized by therapeutic category, were released for public review and comment. Those electing to comment were given the option to select “yes” in support of inclusion, “no” in opposition to inclusion, or “abstain.” Comments related to each measure were also captured. Responses to public review and comments were carefully considered by the PAM Work Group before the final list of measures was determined. Description of measures selected The following section describes the selection process for measures within the 6 therapeutic areas of antithrombotic safety, cardiovascular control, glycemic control, pain management, behavioral health, and antimicrobial stewardship. The measures selected can be used by pharmacists and pharmacy personnel to demonstrate the value of pharmacist services (Table 1). Some measures selected have a “NQF endorsed–reserved” status indicating that the measure is still valid but due to its high level of performance, other measures are to be selected that offer more opportunity for improvement. The SMEs that chose to select a measure with NQF endorsed–reserved status believed that the measure is important for patient safety and connected to pharmacy department performance and therefore warrants continued monitoring. Of the 28 measures analyzed and selected by the work group, 7 were carried forward from the previous PAM Work Group effort, which had selected 21 measures. For the majority of those not carried forward, the reason was either lack or loss of NQF endorsement or failure of the measure to meet the 5 feasibility criteria outlined above. Table 1. Accountability Measures Recommended by the ASHP Pharmacy Accountability Measures Work Groupa Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 aNQF = National Quality Forum, ICU = intensive care unit, VTE = venous thromboembolism, FDA = Food and Drug Administration, ACC = American College of Cardiology, INR = International Normalized Ratio, CMS = Centers for Medicare and Medicaid Services, ACEI = angiotensin-converting enzyme inhibitor, ARB = angiotensin receptor blocker, LVSD = left ventricular systolic dysfunction, AMI = acute myocardial infarction, LVEF = left ventricular ejection fraction, LVS = left ventricular systolic, CABG = coronary artery bypass graft, STS = Society of Thoracic Surgeons, HF = heart failure, ACE = angiotensin-converting enzyme, LVSD = left ventricular systolic dysfunction, AMA-PCPI = American Medical Association-Physician Consortium for Performance Improvement, PQA = Pharmacy Quality Alliance, NCQA = National Committee for Quality Assurance, MED = morphine equivalent dosing, HBIPS = Hospital Based Inpatient Psychiatric Services, PCPI = Physician Consortium for Performance Improvement, CDC = Centers for Disease Control and Prevention, AAB = adults with acute bronchitis, NHSN = National Healthcare Safety Network. bLevel of analysis pertains to the level(s) at which a measure was evaluated for performance. NQF endorsed–reserved is an indication for measures that are valid and reliable and have high levels of performance (i.e. measures that are topped out) but where continued performance monitoring is warranted to prevent decreases in performance. The PAM Work Group believes NQF endorsed–reserved measures still represent an opportunity for pharmacists to be held accountable and demonstrate value. cPrescribing may include, in the outpatient setting, a prescription is given to the patient for ACE inhibitor or ARB therapy at 1 or more visits in the measurement period OR the patient is already taking ACE inhibitor or ARB therapy as documented in current medication list; in the inpatient setting, a prescription is given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy is to be continued after discharge as documented in the discharge medication list. dPrescribing may include, in the outpatient setting, a prescription is given to the patient for beta-blocker therapy at 1 or more visits in the measurement period OR the patient is already taking beta-blocker therapy as documented in current medication list. eBeta-blocker therapy should include bisoprolol, carvedilol, or sustained-release metoprolol succinate (see technical specifications for additional information on medications). fDefined as the number of patients who were present for any portion of each day of a calendar month for each location. The day of admission, discharge, and transfer to and from locations are included in days present. All days present are summed for each location and month, and the aggregate sums for each location-month combination comprise the denominator data for the measure. Open in new tab Table 1. Accountability Measures Recommended by the ASHP Pharmacy Accountability Measures Work Groupa Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 aNQF = National Quality Forum, ICU = intensive care unit, VTE = venous thromboembolism, FDA = Food and Drug Administration, ACC = American College of Cardiology, INR = International Normalized Ratio, CMS = Centers for Medicare and Medicaid Services, ACEI = angiotensin-converting enzyme inhibitor, ARB = angiotensin receptor blocker, LVSD = left ventricular systolic dysfunction, AMI = acute myocardial infarction, LVEF = left ventricular ejection fraction, LVS = left ventricular systolic, CABG = coronary artery bypass graft, STS = Society of Thoracic Surgeons, HF = heart failure, ACE = angiotensin-converting enzyme, LVSD = left ventricular systolic dysfunction, AMA-PCPI = American Medical Association-Physician Consortium for Performance Improvement, PQA = Pharmacy Quality Alliance, NCQA = National Committee for Quality Assurance, MED = morphine equivalent dosing, HBIPS = Hospital Based Inpatient Psychiatric Services, PCPI = Physician Consortium for Performance Improvement, CDC = Centers for Disease Control and Prevention, AAB = adults with acute bronchitis, NHSN = National Healthcare Safety Network. bLevel of analysis pertains to the level(s) at which a measure was evaluated for performance. NQF endorsed–reserved is an indication for measures that are valid and reliable and have high levels of performance (i.e. measures that are topped out) but where continued performance monitoring is warranted to prevent decreases in performance. The PAM Work Group believes NQF endorsed–reserved measures still represent an opportunity for pharmacists to be held accountable and demonstrate value. cPrescribing may include, in the outpatient setting, a prescription is given to the patient for ACE inhibitor or ARB therapy at 1 or more visits in the measurement period OR the patient is already taking ACE inhibitor or ARB therapy as documented in current medication list; in the inpatient setting, a prescription is given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy is to be continued after discharge as documented in the discharge medication list. dPrescribing may include, in the outpatient setting, a prescription is given to the patient for beta-blocker therapy at 1 or more visits in the measurement period OR the patient is already taking beta-blocker therapy as documented in current medication list. eBeta-blocker therapy should include bisoprolol, carvedilol, or sustained-release metoprolol succinate (see technical specifications for additional information on medications). fDefined as the number of patients who were present for any portion of each day of a calendar month for each location. The day of admission, discharge, and transfer to and from locations are included in days present. All days present are summed for each location and month, and the aggregate sums for each location-month combination comprise the denominator data for the measure. Open in new tab Antithrombotic safety Twenty-two antithrombotic measures were derived from the methodology above. For the inpatient setting, appropriate venous thromboembolism (VTE) prophylaxis (as defined in the measure ICU VTE Prophylaxis) remained a high priority, highlighting its continued importance despite being a national quality measure focus for over a decade. Pharmacists improve quality and safety with antithrombotic agents.19 Care for patients receiving antithrombotics continues to evolve with a shift towards risk assessment for both VTE and bleeding to improve care.20 Newer options referred to as direct oral anticoagulants have recently become available for prevention of VTE in orthopedic surgical and acutely ill medical patients. Another measure selected was Anticoagulation Therapy for Atrial Fibrillation/Flutter (initiated at or prior to discharge) in patients with ischemic stroke who have concomitant atrial fibrillation/flutter. This was identified as important due to multiple publications demonstrating continued high rates of anticoagulation omission (~40–50%) in this population.20 In the outpatient setting, Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy was selected, in addition to routine International Normalized Ratio (INR) Monitoring of Individuals on Warfarin Therapy with a frequency of at least every 56 days (8 weeks). Interestingly, the American Heart Association/American College of Cardiology guidelines have shifted to suggest monitoring of warfarin in patients with atrial fibrillation at least every 4 weeks and, therefore, the next measure update may decrease the monitoring interval frequency to be consistent with national guideline recommendations.21 For transitions of care, 2 measures were selected: INR Monitoring for Individuals on Warfarin After Hospital Discharge, which tracks if an INR is obtained within 14 days of discharge, and Discharged on Antithrombotic Therapy, tracking appropriate antithrombotic therapy upon discharge for patients without documented contraindication who have experienced ischemic stroke/transient ischemic attacks (TIA). To summarize, the SMEs maintained a strong focus on appropriate anticoagulant use to optimize patient outcomes by preventing thrombotic events or monitoring anticoagulant safely. In addition to the measures that were identified, the SMEs reached consensus that the outpatient measure on anticoagulation for atrial fibrillation/flutter should be highlighted for similar focus on an inpatient setting, due to its importance. While an outpatient measure exists currently, the SME panel noted it should be targeted as a priority for quality improvement due to the overall poor performance in hospitals nationally and globally leaving many atrial fibrillation patients at risk of ischemic stroke. Alternatively, documentation that the patient was at least offered and declined anticoagulation treatment via a shared decision-making process is acceptable. Cardiovascular control The SMEs began with 25 identified measures for this new PAM area. For the inpatient setting, 2 measures were identified: the use of Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers for Left Ventricular Systolic Dysfunction (LVSD) in Acute Myocardial Infarction (AMI) Patients, and Preoperative Beta Blockade in patients undergoing coronary artery bypass graft (CABG), evaluating if a beta blocker was received within the 24 hours prior to CABG surgery. For the outpatient setting, 2 measures were chosen, both for the heart failure (HF) population with LVSD: ACE Inhibitor or Angiotensin Receptor Blockers Therapy for LVSD and Beta-Blocker Therapy for LVSD. For transition of care, the SMEs selected 2 measures: Beta-Blocker Therapy (specifically with bisoprolol, carvedilol, or sustained-release metoprolol succinate) prescribed at discharge, in the LVSD patient, and Discharged on Statin Medication for ischemic stroke or TIA patients that are discharged on a statin therapy. Overall, there was a clear focus on heart failure—whether alone or in combination with acute myocardial infarction, stroke/TIA, and CABG—and the SME panel prioritized these measures due to the morbidity and mortality reductions demonstrated with appropriate use of these drugs in these populations. Glycemic control Eighteen existing endorsed measures relating to glycemic control were identified, comprising 2 inpatient measures and 16 outpatient measures. The SMEs opted to include both inpatient measures, as a pair of balanced measures that measure the incidence of hypoglycemic and hyperglycemic events. For the outpatient setting, the SMEs selected 2 measures: Statin Use in Persons with Diabetes and Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (>9.0%)—test value greater than 9.0% or missing a result. The American Diabetes Association recommends a patient-centered approach to diabetes care and individualizing glycosylated hemoglobin (HbA1c) goals.22 The HbA1c measure includes tracking of consistent monitoring of HbA1c as well as of poorly controlled diabetes (HbA1c value exceeding 9%). The SMEs recommended this measure as it captures both monitoring and optimization of effective drug therapy. The American Diabetes Association also recommends that all patients with diabetes take a statin to reduce risk for heart disease.22 Pain management In the relatively short time since the publication of the first PAM article, issues related to pain management, use and abuse of opioids, and many related concerns have garnered national attention in the United States. Opioid stewardship is quickly becoming a focused commitment for many health systems. A wave of change in pain management is sweeping across the nation. Pharmacists are engaged in all aspects of medication management for pain. Highly trained and knowledgeable pain management pharmacists are often found in emergency departments, hospice care, oncology, trauma units, and ambulatory care, as well as serving in oversight and consulting roles for health systems. Interestingly, despite the aforementioned high degree of public and even regulatory activity related to opioids and pain management, quality measures targeting these issues have not fully progressed with many measures still under development. Of the 14 existing endorsed measures identified for pain management, 8 were focused on screening for and assessment of pain and 5 were related to medication use. Pharmacists can and do screen and assess pain status, but there were varying opinions as to whether pharmacists in most health systems would be accountable for ensuring this care. Therefore, the 5 measures that were directly related to medication use were selected. Three of these measures were developed by the PQA for identifying and reducing patient harm related to opioid use by targeting opioid dose (standardized to a total daily dose using morphine equivalent dosing) and prescribing (multiple pharmacies and/or prescribers) for non–cancer-related pain (Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer, Use of Opioids at High Dosage in Persons Without Cancer, and Use of Opioids from Multiple Providers in Persons Without Cancer). These measures were designed for use by payers, health plans, and prescription drug plans rather than health systems. However, the SMEs believed the intent of the measures reflected health-systems issues related to pain management, especially in the ambulatory care setting. Another measure, Continuity of Pharmacotherapy for Opioid Use Disorder, was called out as a likely growing role for pharmacy personnel and health systems as more patients are referred to and receive care for opioid addiction and abuse. The SMEs also discussed other emerging pain management—related measures for future consideration. Two of the measures—newly developed by the PQA—include (1) Concurrent use of Opioids and Benzodiazepines and (2) Initial Opioid Prescribing. The third measure—still under development by CMS—is the Hospital Harm Measure for Naloxone Use, which assesses opioid-related adverse respiratory events in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid-related adverse respiratory events or oversedation. This is not a new metric, but it is now being evaluated for more formal inclusion into several CMS quality programs. Behavioral health Decades’ worth of literature illustrates the positive impact pharmacists have as part of the behavioral healthcare team.23,24 Multiple studies demonstrate favorable outcomes in patient satisfaction, clinical markers, and costs when pharmacists are actively involved in behavioral health treatment.25-27 Despite this, there is an established need for consistency in the approach to measuring outcomes in studies of pharmacists improving behavioral healthcare. As a result of growing interest in reducing variability in patient care in this clinical area, a new behavioral health domain has been added to this edition of PAM. The SMEs in this area initially considered a list of 31 measures and concluded that while most of the available measures were adequate assessments of pharmacist activities to improve patient safety in the transition of care and outpatient areas of health systems, none were considered good PAM for the inpatient setting. Consequently, the SME panel only included 2 measures from the NQF database—1 transitional (HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification) and 1 outpatient metric (Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications). The outpatient measure could also be applied to the inpatient setting to address diabetes screening as part of recommended metabolic assessment for people with schizophrenia or bipolar disorder who are using antipsychotic medications. Public comments reinforced this and included suggestions for extending the screening to the pediatric population as well. Finding no other acceptable measures after reviewing the entirety of the NQF and NQMC database, the SME’s proposed quality measures currently in use in their respective organizations. Consensus was reached on checking for lithium monitoring (Patients Taking Lithium With No Recent Monitoring), a measure currently in use in the Veterans Health Administration healthcare system. Notably, the work group concluded that both of the measures they selected had universal applicability in the inpatient and outpatient care settings. Antimicrobial stewardship/infectious diseases Since the work group’s 2014 publication, several significant releases have promoted and advanced antimicrobial stewardship efforts. Key amongst these was the National Action Plan for Combating Antibiotic-Resistant Bacteria, which set aggressive goals to foster antimicrobial stewardship across a wide scope of healthcare settings.18 Release of the CDC Core Elements of Antibiotic Stewardship in the hospital, outpatient, and nursing home settings; and the Joint Commission’s Medication Management standard for hospitals, critical access hospitals, and nursing care centers (MM.09.01.01) complemented existing organizational and international guidelines which detail the valued role of pharmacists in antimicrobial stewardship programs (ASPs).28-31 These guidelines provide a framework to guide the implementation and optimization of ASPs in order to best improve patient outcomes. A review of the NQMC database revealed that neither the CDC Core Elements for Antibiotic Stewardship nor many of the specific recommendations contained within are endorsed by NQF. The work group acknowledged the importance of the Core Elements for all settings and chose to include it in the suite of recommendations, regardless of endorsement status. The CDC’s National Healthcare Safety Network’s Antimicrobial Use Measure (NQF-endorsed measure 2720) complements the Core Elements and facilitates the tracking, reporting, and benchmarking of antimicrobial use within ASPs and nationally. The work group felt adoption was important for pharmacy departments and ASPs to strive for since reporting is currently not universal. A review of the NQMC database identified 36 additional infectious diseases–related measures. These measures were developed by a wide variety of stakeholders and involve many syndrome-specific focuses in the inpatient and outpatient settings and during transitions of care. In general, limiting selections was difficult. Nearly all measures examined scored highly on the predefined criteria. The work group acknowledged the important role pharmacists play in promoting and conducting proper immunization of patients in all organized healthcare settings and in the community.32 An influenza immunization measure (Preventive Care and Screening: Influenza Immunization, NQF 0041) was selected for inclusion due to an ongoing performance gap, the morbidity and mortality associated with the disease, and low immunization rates overall despite topped out measures in the inpatient setting. The final work group selection was a carry-over from the previous work group (NQF 0058)—Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. Bronchitis and other acute respiratory tract infections remain both associated with a high degree of unnecessary antibiotic prescribing and an important starting target disease state for ASPs in outpatient settings.30 Future steps Pharmacy departments should continue to drive quality measure monitoring and process improvement relating to quality, safety, adverse events, efficiency, cost and resource use, access, and other healthcare metrics within institutions, where possible, and strive to publish results of efforts to ascertain the effects of various staffing and practice models on performance. Opportunities for internal and external benchmarking of quality measures enable monitoring, reporting, and attributing medication management service value. In an effort to support implementation of these recommendations, the PAM Work Group enlisted expertise to develop pseudocodes for the selected measures. The pseudocodes outline specifications to create algorithms for internal benchmarking. To access the pseudocodes go to: https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Quality-Improvement/Pharmacy-Accountability-Measures. The PAM Work Group recognizes the need to further refine the approach as described in this article. We anticipate that the work group’s future considerations will include, although not be limited too, determining the optimal quality measure database search methodology, incorporating commercial payer quality measure consideration, and including interdisciplinary review and discussion. Conclusion As the healthcare landscape continues to shift away from rewarding volume of patient care services to rewarding value and quality of patient care services, pharmacists have an opportunity to positively impact patient care outcomes while demonstrating value to both the patient and health systems. The national emphasis on quality measures has significantly increased the number of measures available. A process to review and select quality measures is described in this article, with the goal of simplifying health-system pharmacy departments’ efforts to identify important measures to influence. Acknowledgments The contributions of the following individuals are acknowledged: Anna Legreid Dopp, Pharm.D; Behavioral Health Subject Matter Experts Chris Paxos, Pharm.D., BCPP, BCPS, BCGP; Ericka L. Breden Crouse, Pharm.D., BCPP, CGP; Jonathan G Leung, Pharm.D., BCPS, BCPP; Jennifer Alastanos, Pharm.D., BCPP; Heather M. Mooney, Pharm.D., BCPS, BCPP; and Tera D. Moore, Pharm.D., BCPS, BCACP; Glycemic Control Subject Matter Experts Daniel M. Riche, Pharm.D., FCCP, BCPS, CDE, ASH-CHC, CLS; Jacqueline L. Olin, M.S., Pharm.D., BCPS, CDE, FASHP, FCCP; Amy Henneman, Pharm.D., BCACP, BCPS, CDE; Rachel Heilmann, Pharm.D., BCPS; Andrew B. Forest, Pharm D, BCPS; Pamela L. Stamm, Pharm.D., BCPS, BCACP, CDE, FASHP; and Adraine L. Lyles, Pharm.D., BCPS, CDE; Pain Management Subject Matter Experts Maria Foy, Pharm.D., BCPS, CPE; Suzanne Nesbit, Pharm.D., BCPS, CPE, FCCP; Lee Kral, Pharm.D., Mary Lynn McPherson, Pharm.D.; Courtenay Wilson, Pharm.D., BCPS, BCACP, CDE, CPP; and Amanda Locke, Pharm.D., BCACP; Antithrombotic/Cardiovascular Subject Matter Experts Toby Trujillo, Pharm.D., FCCP, FAHA, BCPS-AQ Cardiology; Allison Burnett, Pharm.D., CACP, Ph.C.; Snehal Bhatt, Pharm.D., BCPS, FASHP; Karen Berger, Pharm.D., BCPS, BCCCP; Deborah Caraballo-Colon, Pharm.D., Ph.C., BCPS-AQ Cardiology; Tuesdy Horner, Pharm.D., Ph.C.; and Michael Gulseth, Pharm.D., BCPS, FASHP; and Antimicrobial Stewardship Subject Matter Experts Curtis Collins, Pharm.D., M.S., BCPS, BCPS-AQ ID, FASHP; Edina Avdic, Pharm.D., M.B.A., BCPS-AQ ID; Sara Revolinski, Pharm.D., BCPS; Lucas Schulz, Pharm.D., BCPS-AQ ID; and Whitney Buckel, Pharm.D. Pseudocode developers: Nick Schutz, Pharm.D.; Janice M. Taylor, Pharm.D, BCPS. 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This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png American Journal of Health-System Pharmacy Oxford University Press http://www.deepdyve.com/lp/oxford-university-press/recommended-quality-measures-for-health-system-pharmacy-2019-update-zCK0GT48xF

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Publisher: Oxford University Press
Copyright: © American Society of Health-System Pharmacists 2019. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.
ISSN: 1079-2082
eISSN: 1535-2900
DOI: 10.1093/ajhp/zxz069
Publisher site: See Article on Publisher Site

Abstract

Abstract Purpose Pharmacists are accountable for medication-related services provided to patients. As payment models transition from reimbursement for volume to reimbursement for value, pharmacy departments must demonstrate improvements in patient care outcomes and quality measure performance. The transition begins with an awareness of quality measures for which pharmacists and pharmacy personnel can demonstrate accountability across the continuum of care. The objective of the Pharmacy Accountability Measures (PAM) Work Group is to identify measures for which pharmacy departments can and should assume accountability. Summary The National Quality Forum (NQF) Quality Positioning System (QPS) was queried for NQF-endorsed medication-related measures. Included measures were curated into a data set of 6 therapeutic categories: antithrombotic safety, cardiovascular control, glucose control, pain management, behavioral health, and antimicrobial stewardship. Subject matter expert (SME) panels assigned to each area analyzed each measure according to a predetermined ranking system developed by the PAM Work Group. Measures remaining after SME review were disseminated during a public comment period for review and ballot. Over 1,000 measures are captured in the NQF QPS; 656 of the measures were found to be endorsed and medication use related or impacted by medication management services. A single reviewer categorized 140 measures into therapeutic categories for SME review; the remaining measures were unrelated to those clinical domains. The SME groups identified 28 measures for inclusion. Conclusion An understanding of the endorsed quality measures available for public reporting programs provides an opportunity for pharmacists to demonstrate accountability for performance, thus improving quality and safety and demonstrating value of care provided. accountability, dashboard, medication quality, metrics, pharmacist value, quality measures, value KEY POINTS As the healthcare landscape continues to shift from fee-for-service reimbursement to value-based purchasing, pharmacists have an opportunity to demonstrate value as a member of the care team. Quality measures assist in the evaluation of healthcare processes, outcomes, patient experience of care, and organizational structure that are attributable to a provider or facility. This article outlines a framework and makes recommendations for health-system pharmacists and pharmacy departments to identify important measures to benchmark and, ultimately, improve upon their performance. In 2014, ASHP convened the Pharmacy Accountability Measures (PAM) Work Group to identify quality measures that demonstrate the value of health-system pharmacists in improving patient safety and health outcomes.1 Since then, the healthcare landscape has continued transitioning toward improving quality, safety, and efficiency. Pressures from a number of fronts are rapidly driving changes to reduce variability, improve quality and safety, and decrease costs in care delivery. Sweeping changes spurred by the Patient Protection and Affordable Care Act of 2010 and Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 impact health systems and signify certainty in the shift towards value-based payment for healthcare. For health systems, there are 3 prominent Centers for Medicare and Medicaid Services (CMS) value-based programs designed to link performance to payment in the hospital setting: the Hospital Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Conditions Reduction Program.2 The Hospital Value-Based Purchasing Program and Hospital Readmissions Reduction Program went into effect in 2012, while the Hospital-Acquired Conditions Reduction Program went into effect in 2014. These programs provide Medicare payment incentives for positive outcomes and/or withhold payments to penalize negative outcomes. For outpatient providers, MACRA authorized the Quality Payment Program to make Medicare payments based on value instead of volume. The Merit-Based Incentive Payment System provides performance-based payment adjustments to providers; participation in Alternative Payment Models also provides incentive payments. In addition to these CMS value-based payment programs there is pressure from other stakeholders and payers to reimburse for value. In this environment, health systems must create new efficiencies by redesigning patient care models, using high-value supplies, outsourcing services, and considering performance-based contracts with vendors and employees.3 Accountability As previous recommendations from the PAM Work Group were published, the Department of Health and Human Services (HHS) released the National Action Plan for Adverse Drug Event (ADE) Prevention.4 The National Action Plan was initiated in response to a bipartisan letter from the U.S. Senate urging action to address ADEs regarding recent literature describing hospitalizations attributable to common medications or medication classes.5,6 In short order, HHS convened a federal interagency steering committee, and the resulting publication identified 3 high-impact medication classes: opioids, anticoagulants, and diabetes agents.4 This publication has garnered national attention and highlighted urgency for accountability in safe medication use. Team-based care models and health-system continuity between inpatient and outpatient settings allow the health-system pharmacist to be an equal contributor to patient care. The increasing focus on value in healthcare provides a unique opportunity for the pharmacy profession not only to participate on the care team but also to actively accept and assert accountability for medication-related and overall patient outcomes.7 Pharmacists can and should assume leadership roles across their respective organizations by engaging all relevant stakeholders to implement improvements that advance organizational performance, particularly for medication-related care. While there is evidence demonstrating pharmacist contributions in improving clinical outcomes and decreasing cost of care, the programs and interventions described tend to be developed locally and often lack universal applicability.8,9 No consolidated list of quality measures that clearly identifies activities or outcomes for which pharmacists should be responsible or accountable exists. The goal of the previous work group was to identify a suite of measures that address preventable harm and improve patient outcomes in the inpatient and outpatient settings that could be adopted universally on pharmacy departmental and organizational dashboards to reflect and demonstrate accountability. The goals of the current project revision remain consistent with the previous effort. The focus of the current PAM Work Group is to identify a revised suite of measures that globally address safety and quality in the inpatient and outpatient settings and during transitions of care. First, the work group identified quality measures that are most important for pharmacists within healthcare organizations to assume accountability for and demonstrate the value of pharmacist services. Second, by concentrating emphasis on the most important measures, pharmacy departments will have a more positive impact by improving performance of the identified measures. Third, by demonstrating improved performance on measures with patients, physicians, nurses, and other healthcare professionals, the pharmacy profession raises awareness of its value to patient care and the healthcare system. Quality measures overview Measuring performance of care intends to optimize the quality, safety, effectiveness, and efficiency of the care provided.10,11 Without measuring performance on standardized measures, quality and safety of care cannot be assessed, nor can the level of care be compared between healthcare systems. In general, quality measures have demonstrated improvements in care and allowed incentivized payment systems to evolve to reward higher-performing systems while withholding payments for lower-performing systems. For instance, National Quality Forum (NQF)–endorsed measures are purported to have saved nearly $30 billion to the healthcare system and to have reduced surgical infection rates by 16%, patient harm by 21%, and early elective C-section deliveries by 89%.12 CMS currently contracts with NQF as an independent third party to assess quality measures developed by measure stewards to determine if they should be endorsed as measures for federal and commercial reporting programs. NQF has a refined endorsement process including a rigorous criteria-based review by a committee of experts representing multiple industry stakeholders using its Consensus Development Process.13 Examples of measure stewards include CMS, the Centers for Disease Control and Prevention (CDC), American Heart Association, American College of Cardiology, and Pharmacy Quality Alliance (PQA), to name a few. Typically, measures must have significant evidence in primary studies and Cochrane and systematic reviews and be supported by national guidelines with data demonstrating significant reductions in morbidity and/or mortality. In addition, the NQF Measure Applications Partnership guides HHS on its selection of quality measures across more than 20 federal public reporting programs.14 Project description Beginning in 2018, the PAM Work Group initiated efforts to review and update the inaugural suite of pharmacy accountability measures that were published in 2014. In this update, the work group reviewed and expanded the clinical topic areas, considered previous and new measures for inclusion within each area, added measures for transitions of care within each area, and tested a methodology for ongoing and continuous updates to the PAM. Relevance In many healthcare settings, quality measures are a common focus for medical, hospital, pharmacy, and nursing staff; however, measure compliance is typically managed and addressed by quality and safety personnel. Historically, manual processes have been used to collect and analyze clinical data or ensure accuracy of claims-based measures. With the transition to electronic health records (EHRs), much data necessary for tracking quality measures is available in the form of readily retrievable clinical data fields that are becoming increasingly more standardized with the development and implementation of interoperability standards. This process will continue to evolve, making clinical data retrieval more efficient and standardized. Indeed, standardization of quality measure numerators and denominators for electronic retrieval can allow comparison across health systems.15 As the pharmacy profession has evolved to a more cognitive and clinical care role, with a shift towards decentralized services in acute and ambulatory care settings, pharmacists and pharmacy departments are uniquely positioned within health systems to more visibly take accountability for quality measures and have a positive impact on performance. While pharmacy personnel are a relatively small labor pool compared with others, interaction with nursing personnel, physicians, other advanced practice clinicians, and patients is common, and pharmacists have many tools available to assess patients and document outcomes within the EHR. This unique positioning allows pharmacists to assess patients, implement manual or electronic clinical decision support, review complex drug therapies, collaborate to implement therapeutic plans, and change the health system’s performance. In addition, pharmacists often have a scope of practice that may allow direct implementation of a new therapeutic plan allowing improved documentation in the EHR. Numerous studies and systematic reviews have demonstrated a positive impact on performance of quality measures with inclusion of pharmacists as part of the care team.9 Raising awareness of which measures are most important and which measures pharmacy is best positioned to significantly impact may increase pharmacy profession accountability to improve healthcare outcomes. The portfolio of measures is constantly changing, with measures being added, assessed for continuation (maintained), or retired. The PAM Work Group project assists with identifying the most important measures in order to simplify the pharmacy profession’s prioritization efforts. Thus, the relevance of this project is broad, given pharmacists’ unique positioning and demonstrated ability to positively impact quality, efficiency, and safety within health systems. Often driven by population health strategies and efforts to reduce readmissions and manage length of stay, the need to reduce unwarranted variation in clinical care and improve patient outcomes by managing transitions of care between settings along the care continuum continues to be a top priority. Therefore, the transition-of-care setting was added to the previous inpatient and outpatient categories for this review. Pharmacists are uniquely trained and positioned to improve care transitions by effectively communicating with the patient and the appropriate members of the healthcare team. Process for identifying measures A survey of available healthcare quality repositories revealed tremendous expansion in the area of quality measures since the initial PAM work. The group decided to consider the entire database of National Quality Measure Clearinghouse (NQMC) measures and the NQF-endorsed measures, accessible through the NQF Quality Positioning System (QPS), as sole sources for potential PAM candidates.16,17 NQMC is a database of specific evidence-based healthcare quality measures that rely on the submitter to provide substantive evidence of the reliability and validity of the proposed measure or demonstrate that the measure has been vetted by another organization that promotes rigorous development and use of measurement in healthcare (e.g., NQF).16 The NQF QPS is a measure search tool that allows queries based on measure type, endorsement status, measure steward, use in federal program, clinical condition/topic area, care setting, National Quality Strategy priority, actual/planned use, data source, level of analysis, and target population.17 Due to reductions in the NQMC budgetary appropriation, database updates after July 2018 have been limited to CMS-developed measures; therefore, the PAM Work Group decided to exclusively access NQF-endorsed measures archived in the QPS when considering measures for inclusion. The 4 screening criteria used to determine if a measure was “pharmacy related” were that the measure (1) was predominately medication related, (2) involved monitoring directly associated with medication therapy, (3) involved monitoring directly related to a clinical domain of interest, or (4) targeted common interventions associated with pharmacy practice (e.g., correcting errors of omission of drug therapy, optimizing drug selection and dosing, reducing the risk of an ADE). If any of the criteria were satisfied, the measure was included in the initial measure set for review. A single reviewer examined all medication-related and pharmacy-sensitive endorsed measures from the NQF QPS (n = 656) and classified them into the original PAM Work Group clinical domains (anticoagulant safety, glycemic control, antimicrobial stewardship, and pain management). However, the results of the measure screening and classification showed a significant number of measures were in categories that fell outside of the original PAM clinical domains. With further consideration, 4 potential new domains were identified for the group to consider: (1) behavioral health, (2) comprehensive medication review, (3) polypharmacy, and (4) pharmacy/medication systems. The work group decided it was valuable to adequately address emerging clinical and therapeutic areas of importance while continuing to consider measures tied to national strategies for improving health. The consensus was to include the 3 original PAM clinical domains in concert with the 3 initial targets of the National Action Plan for ADE Prevention (anticoagulants, hypoglycemics, and opioids), continue the antimicrobial stewardship domain (also now tied to a National Action Plan for Combating Antibiotic-resistant Bacteria), and include 2 new clinical domains, behavioral health and cardiovascular control.4,18 Once measures were divided into the selected domains, 140 measures remained. Figure 1 depicts the process for identifying and reviewing the selected measures. Figure 1. Open in new tabDownload slide Process for selecting pharmacy accountability measures. Figure 1. Open in new tabDownload slide Process for selecting pharmacy accountability measures. Measures endorsed by NQF have met robust criteria of importance, scientific acceptability, feasibility, validity, and usability and use. Those conditions are met during the measure development and endorsement process; however, healthcare leaders need an approach to identify the measures and outcomes that matter most to their organization. Previously, Chassin et al.10 and Baker and Chassin11 outlined criteria for considering accountability measures that evaluate processes and outcomes of care, respectively. For the purpose of this effort, the PAM Work Group referenced those criteria and modified feasibility criteria for evaluation of pharmacy-sensitive process and outcome measures, as follows: There is strong evidence that the metric improvement leads to better outcomes. The measure accurately captures whether evidence-based care has been provided. Data for the measure are readily available and retrievable without undue burden. Implementing the measure has little or no chance of inducing unintended consequences. Improvement of the measure is understandable, useful, and meaningful to stakeholders (e.g., patients, providers, payers). After initial measure refinement, the subsets were sent to SMEs for final measure selection. Each SME panel was asked to rank measures according to the 5 feasibility criteria, using a Likert-type scale; the measures receiving the highest scores were retained for public comment. The SME panels were composed of pharmacists with notable clinical experience and training around the respective clinical domains of the measure sets. These panels determined the relevance of the measures to pharmacy practice and the level of accountability, stratified the measures according to the above feasibility criteria, and selected the best measures for each care setting (inpatient, outpatient, and transition, respectively). Lastly, the selected measures, organized by therapeutic category, were released for public review and comment. Those electing to comment were given the option to select “yes” in support of inclusion, “no” in opposition to inclusion, or “abstain.” Comments related to each measure were also captured. Responses to public review and comments were carefully considered by the PAM Work Group before the final list of measures was determined. Description of measures selected The following section describes the selection process for measures within the 6 therapeutic areas of antithrombotic safety, cardiovascular control, glycemic control, pain management, behavioral health, and antimicrobial stewardship. The measures selected can be used by pharmacists and pharmacy personnel to demonstrate the value of pharmacist services (Table 1). Some measures selected have a “NQF endorsed–reserved” status indicating that the measure is still valid but due to its high level of performance, other measures are to be selected that offer more opportunity for improvement. The SMEs that chose to select a measure with NQF endorsed–reserved status believed that the measure is important for patient safety and connected to pharmacy department performance and therefore warrants continued monitoring. Of the 28 measures analyzed and selected by the work group, 7 were carried forward from the previous PAM Work Group effort, which had selected 21 measures. For the majority of those not carried forward, the reason was either lack or loss of NQF endorsement or failure of the measure to meet the 5 feasibility criteria outlined above. Table 1. Accountability Measures Recommended by the ASHP Pharmacy Accountability Measures Work Groupa Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 aNQF = National Quality Forum, ICU = intensive care unit, VTE = venous thromboembolism, FDA = Food and Drug Administration, ACC = American College of Cardiology, INR = International Normalized Ratio, CMS = Centers for Medicare and Medicaid Services, ACEI = angiotensin-converting enzyme inhibitor, ARB = angiotensin receptor blocker, LVSD = left ventricular systolic dysfunction, AMI = acute myocardial infarction, LVEF = left ventricular ejection fraction, LVS = left ventricular systolic, CABG = coronary artery bypass graft, STS = Society of Thoracic Surgeons, HF = heart failure, ACE = angiotensin-converting enzyme, LVSD = left ventricular systolic dysfunction, AMA-PCPI = American Medical Association-Physician Consortium for Performance Improvement, PQA = Pharmacy Quality Alliance, NCQA = National Committee for Quality Assurance, MED = morphine equivalent dosing, HBIPS = Hospital Based Inpatient Psychiatric Services, PCPI = Physician Consortium for Performance Improvement, CDC = Centers for Disease Control and Prevention, AAB = adults with acute bronchitis, NHSN = National Healthcare Safety Network. bLevel of analysis pertains to the level(s) at which a measure was evaluated for performance. NQF endorsed–reserved is an indication for measures that are valid and reliable and have high levels of performance (i.e. measures that are topped out) but where continued performance monitoring is warranted to prevent decreases in performance. The PAM Work Group believes NQF endorsed–reserved measures still represent an opportunity for pharmacists to be held accountable and demonstrate value. cPrescribing may include, in the outpatient setting, a prescription is given to the patient for ACE inhibitor or ARB therapy at 1 or more visits in the measurement period OR the patient is already taking ACE inhibitor or ARB therapy as documented in current medication list; in the inpatient setting, a prescription is given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy is to be continued after discharge as documented in the discharge medication list. dPrescribing may include, in the outpatient setting, a prescription is given to the patient for beta-blocker therapy at 1 or more visits in the measurement period OR the patient is already taking beta-blocker therapy as documented in current medication list. eBeta-blocker therapy should include bisoprolol, carvedilol, or sustained-release metoprolol succinate (see technical specifications for additional information on medications). fDefined as the number of patients who were present for any portion of each day of a calendar month for each location. The day of admission, discharge, and transfer to and from locations are included in days present. All days present are summed for each location and month, and the aggregate sums for each location-month combination comprise the denominator data for the measure. Open in new tab Table 1. Accountability Measures Recommended by the ASHP Pharmacy Accountability Measures Work Groupa Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 Measure Title/Description Setting of Care/Level of Analysisb Numerator Denominator Measure Developer/Endorsement Status Antithrombotic safety Anticoagulation Therapy for Atrial Fibrillation/Flutter Inpatient/facility Patients with ischemic stroke prescribed anticoagulation therapy at hospital discharge Ischemic stroke patients with documented atrial fibrillation/flutter Joint Commission/NQF endorsed–reserved: 0436 ICU VTE Prophylaxis Inpatient/facility Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: • the day of or the day after ICU admission (or transfer) • the day of or the day after surgery end date for surgeries that start the day of or the day after ICU admission (or transfer) Patients directly admitted or transferred to ICU Joint Commission/NQF endorsed: 0372 Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy Outpatient/clinician: individual Patients who are prescribed warfarin or another oral anticoagulant drug that is FDA approved for the prevention of thromboembolism All patients aged 18 years and older with a diagnosis of nonvalvular atrial fibrillation or atrial flutter whose assessment of the specified thromboembolic risk factors indicates 1 or more high-risk factors or more than 1 moderate risk factor, as determined by CHADS2 risk stratification ACC/NQF endorsed: 1525 INR Monitoring for Individuals on Warfarin Outpatient/clinician: group practice, health plan, integrated delivery system Percentage of individuals 18 years of age and older with at least 56 days of warfarin therapy who receive an INR test during each 56-day interval with warfarin The number of individuals in the denominator who have at least 1 INR monitoring test during each 56-day interval with active warfarin therapy CMS/NQF endorsed: 0555 INR Monitoring for Individuals on Warfarin after Hospital Discharge Transition/facility Percentage of adult inpatient hospital discharges to home for which the individual was on warfarin and discharged with a non-therapeutic INR who had an INR test within 14 days of hospital discharge Individuals in the denominator who had an INR test within 14 days of discharge CMS/NQF endorsed: 2732 Discharged on Antithrombotic Therapy Transition/facility Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0435 Cardiovascular control ACEI or ARB for LVSD-AMI patients. Inpatient/transition/facility AMI patients who are prescribed an ACEI or ARB at hospital discharge AMI patients (International Classification of Diseases, 9th revision, Clinical Modification [ICD-9-CM] principal diagnosis code of AMI: 410.00, 410.01, 410.10, 410.11, 410.20, 410.21, 410.30, 410.31, 410.40, 410.41, 410.50, 410.51, CMS/NQF endorsed–reserved: 0137 410.60, 410.61, 410.70, 410.71, 410.80, 410.81, 410.90, 410.91); with chart documentation of a of <40% or a narrative description of LVS function consistent with moderate or severe systolic dysfunction Preoperative Beta Blockade Inpatient/clinician: group practice, facility Percentage of patients aged 18 years and older undergoing isolated CABG who received beta blockers within 24 hours preceding surgery Number of patients undergoing isolated CABG who received beta blockers within 24 hours preceding surgery STS/NQF endorsed: 0127 HF: ACE Inhibitor or ARB Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedc ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% AMA-PCPI/NQF endorsed: 0081 HF: Beta-Blocker Therapy for LVSD Outpatient/clinician: group practice, individual Patients who were prescribedd beta-blocker therapye either within a 12-month period when seen in the outpatient setting or at hospital discharge All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF of <40% LVEF of <40% corresponds to qualitative documentation of moderate dysfunction or severe dysfunction AMA-PCPI/NQF endorsed: 0083 Beta-Blocker Therapy (i.e., Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate) for LVSD Prescribed at Discharge Transition/facility Patients who are prescribed bisoprolol, carvedilol, or sustained-release metoprolol succinate for LVSD at hospital discharge HF patients with current or prior documentation of LVEF of <40% Joint Commission/NQF endorsed: 2438 Discharged on Statin Medication Transition/facility Ischemic stroke patients prescribed statin medication at hospital discharge Ischemic stroke patients Joint Commission/NQF endorsed–reserved: 0439 Glycemic control Statin Use in Persons with Diabetes Outpatient/health plan The number of patients in the denominator who received a prescription fill for a statin or statin combination during the measurement year The denominator includes subjects aged 41–75 years as of the last day of the measurement year who are continuously enrolled during the measurement period. Subjects include patients who were dispensed 2 or more prescription fills for a hypoglycemic agent during the measurement year PQA/NQF endorsed: 2712 Glycemic Control—Hypoglycemia Inpatient/facility Total number of hypoglycemic events (<40 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Optional numerator: Total number of hypoglycemic events (<70 mg/dL) that were preceded by administration of rapid/short-acting insulin within 12 hours or an anti-diabetic agent other than short-acting insulin within 24 hours, were not followed by another glucose value greater than 80 mg/dL within 5 minutes, and were at least 20 hours apart Total number of hospital days with at least 1 anti-diabetic agent administered CMS/NQF endorsed: 2363 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) Outpatient/health plan, integrated delivery system Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or for whom an HbA1c test was not done during the measurement year. The outcome is an out-of-range result of an HbA1c test, indicating poor control of diabetes. Poor control puts the individual at risk for complications including renal failure, blindness, and neurologic damage. There is no need for risk adjustment for this intermediate outcome measure Patients 18–75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year NCQA/NQF endorsed: 0059 Glycemic Control—Hyperglycemia Inpatient/facility Sum of the percentage of hospital days in hyperglycemia for each admission in the denominator Total number of admissions with a diagnosis of diabetes mellitus, at least 1 administration of insulin or any anti-diabetic medication except metformin, or at least 1 elevated blood glucose value (>200 mg/dL [11.1 mmol/L]) at any time during the entire hospital stay CMS/NQF endorsed: 2362 Pain management Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer, AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) AND who received opioid prescriptions from 4 or more prescribers AND 4 or more pharmacies PAQ/NQF endorsed: 2951 Use of Opioids at High Dosage in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids with a daily dosage greater than 120 mg MED for 90 consecutive days or longer Any member in the denominator with opioid prescription claims where the MED is greater than 120 mg for 90 consecutive days or longer (MED calculation included in measure details) PQA/NQF endorsed: 2940 Use of Opioids from Multiple Providers in Persons Without Cancer Outpatient/health plan The proportion (XX out of 1,000) of individuals without cancer receiving prescriptions for opioids from 4 or more prescribers AND 4 or more pharmacies Any member in the denominator who received opioid prescription claims from 4 or more prescribers AND 4 or more pharmacies PQA/NQF endorsed: 2950 Patients Treated with an Opioid who are Given a Bowel Regimen Inpatient and outpatient/clinician: group practice, individual, facility, health plan Percentage of vulnerable adults treated with an opioid that are offered/prescribed a bowel regimen or documentation of why this was not needed Patients from the denominator that are given a bowel regimen or there is documentation as to why this was not needed RAND Corporation/NQF endorsed: 1617 Continuity of Pharmacotherapy for Opioid Use Disorder Outpatient/health plan Percentage of adults 18–64 years of age with pharmacotherapy for opioid use disorder who have at least 180 days of continuous treatment Individuals in the denominator who have at least 180 days of continuous pharmacotherapy with a medication prescribed for opioid use disorder without a gap of more than 7 days University of Southern California/NQF endorsed: 3175 Behavioral health Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications Inpatient and outpatient/health plan, integrated delivery system Among patients 18–64 years of age with schizophrenia or bipolar disorder, those who were dispensed an antipsychotic medication and had a diabetes screening testing during the measurement year Patients 18–64 years of age as of the end of the measurement year (e.g., December 31) with a schizophrenia or bipolar disorder diagnosis and who were prescribed an antipsychotic medication NCQA/NQF endorsed: 1932 Patients Taking Lithium With No Recent Monitoring Inpatient and outpatient/facility Percent of patients prescribed lithium without lithium level in past 6 months or serum creatinine in past 12 months Patients with an active prescription for lithium without required laboratory test results Department of Veterans Affairs/Not endorsed HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification Transition/facility Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications with appropriate justification Psychiatric inpatients discharged on 2 or more routinely scheduled antipsychotic medications Joint Commission/NQF endorsed: 0560 Antimicrobial stewardship Preventive Care and Screening: Influenza Immunization Transition/clinician: group practice, individual Patients who received an influenza immunization OR who reported previous receipt of an influenza immunization All patients aged 6 months and older seen for a visit between October 1 and March 31 PCPI/NQF endorsed: 0041 Core Elements of Antibiotic Stewardship Inpatient, outpatient, and nursing homes/facility Implementation of individual Core Element Total Core Elements CDC/Not endorsed Avoidance of Antibiotic Treatment in AAB Outpatient/health plan, integrated delivery system Patients who were dispensed antibiotic medication on or 3 days after the index episode start date (a higher rate is better). The measure is reported as an inverted rate (i.e., 1 – numerator/denominator) to reflect the number of people that were not dispensed an antibiotic All patients 18 years of age as of January 1 of the year prior to the measurement year to 64 years as of December 31 of the measurement year with an outpatient or emergency department visit with any diagnosis of acute bronchitis during the intake period (January 1–December 24 of the measurement year) NCQA/NQF endorsed: 0058 NHSN Antimicrobial Use Measure Inpatient/facility Days of antimicrobial therapy for antibacterial agents administered to adult and pediatric patients in medical, medical/surgical, and surgical wards and medical, medical/surgical, and surgical intensive care units Days present for each patient care location—adult and pediatric medical, medical/surgical, and surgical wards and adult and pediatric medical, medical/surgical, and surgical intensive care unitsf CDC/NQF endorsed: 2720 aNQF = National Quality Forum, ICU = intensive care unit, VTE = venous thromboembolism, FDA = Food and Drug Administration, ACC = American College of Cardiology, INR = International Normalized Ratio, CMS = Centers for Medicare and Medicaid Services, ACEI = angiotensin-converting enzyme inhibitor, ARB = angiotensin receptor blocker, LVSD = left ventricular systolic dysfunction, AMI = acute myocardial infarction, LVEF = left ventricular ejection fraction, LVS = left ventricular systolic, CABG = coronary artery bypass graft, STS = Society of Thoracic Surgeons, HF = heart failure, ACE = angiotensin-converting enzyme, LVSD = left ventricular systolic dysfunction, AMA-PCPI = American Medical Association-Physician Consortium for Performance Improvement, PQA = Pharmacy Quality Alliance, NCQA = National Committee for Quality Assurance, MED = morphine equivalent dosing, HBIPS = Hospital Based Inpatient Psychiatric Services, PCPI = Physician Consortium for Performance Improvement, CDC = Centers for Disease Control and Prevention, AAB = adults with acute bronchitis, NHSN = National Healthcare Safety Network. bLevel of analysis pertains to the level(s) at which a measure was evaluated for performance. NQF endorsed–reserved is an indication for measures that are valid and reliable and have high levels of performance (i.e. measures that are topped out) but where continued performance monitoring is warranted to prevent decreases in performance. The PAM Work Group believes NQF endorsed–reserved measures still represent an opportunity for pharmacists to be held accountable and demonstrate value. cPrescribing may include, in the outpatient setting, a prescription is given to the patient for ACE inhibitor or ARB therapy at 1 or more visits in the measurement period OR the patient is already taking ACE inhibitor or ARB therapy as documented in current medication list; in the inpatient setting, a prescription is given to the patient for beta-blocker therapy at discharge OR beta-blocker therapy is to be continued after discharge as documented in the discharge medication list. dPrescribing may include, in the outpatient setting, a prescription is given to the patient for beta-blocker therapy at 1 or more visits in the measurement period OR the patient is already taking beta-blocker therapy as documented in current medication list. eBeta-blocker therapy should include bisoprolol, carvedilol, or sustained-release metoprolol succinate (see technical specifications for additional information on medications). fDefined as the number of patients who were present for any portion of each day of a calendar month for each location. The day of admission, discharge, and transfer to and from locations are included in days present. All days present are summed for each location and month, and the aggregate sums for each location-month combination comprise the denominator data for the measure. Open in new tab Antithrombotic safety Twenty-two antithrombotic measures were derived from the methodology above. For the inpatient setting, appropriate venous thromboembolism (VTE) prophylaxis (as defined in the measure ICU VTE Prophylaxis) remained a high priority, highlighting its continued importance despite being a national quality measure focus for over a decade. Pharmacists improve quality and safety with antithrombotic agents.19 Care for patients receiving antithrombotics continues to evolve with a shift towards risk assessment for both VTE and bleeding to improve care.20 Newer options referred to as direct oral anticoagulants have recently become available for prevention of VTE in orthopedic surgical and acutely ill medical patients. Another measure selected was Anticoagulation Therapy for Atrial Fibrillation/Flutter (initiated at or prior to discharge) in patients with ischemic stroke who have concomitant atrial fibrillation/flutter. This was identified as important due to multiple publications demonstrating continued high rates of anticoagulation omission (~40–50%) in this population.20 In the outpatient setting, Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy was selected, in addition to routine International Normalized Ratio (INR) Monitoring of Individuals on Warfarin Therapy with a frequency of at least every 56 days (8 weeks). Interestingly, the American Heart Association/American College of Cardiology guidelines have shifted to suggest monitoring of warfarin in patients with atrial fibrillation at least every 4 weeks and, therefore, the next measure update may decrease the monitoring interval frequency to be consistent with national guideline recommendations.21 For transitions of care, 2 measures were selected: INR Monitoring for Individuals on Warfarin After Hospital Discharge, which tracks if an INR is obtained within 14 days of discharge, and Discharged on Antithrombotic Therapy, tracking appropriate antithrombotic therapy upon discharge for patients without documented contraindication who have experienced ischemic stroke/transient ischemic attacks (TIA). To summarize, the SMEs maintained a strong focus on appropriate anticoagulant use to optimize patient outcomes by preventing thrombotic events or monitoring anticoagulant safely. In addition to the measures that were identified, the SMEs reached consensus that the outpatient measure on anticoagulation for atrial fibrillation/flutter should be highlighted for similar focus on an inpatient setting, due to its importance. While an outpatient measure exists currently, the SME panel noted it should be targeted as a priority for quality improvement due to the overall poor performance in hospitals nationally and globally leaving many atrial fibrillation patients at risk of ischemic stroke. Alternatively, documentation that the patient was at least offered and declined anticoagulation treatment via a shared decision-making process is acceptable. Cardiovascular control The SMEs began with 25 identified measures for this new PAM area. For the inpatient setting, 2 measures were identified: the use of Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers for Left Ventricular Systolic Dysfunction (LVSD) in Acute Myocardial Infarction (AMI) Patients, and Preoperative Beta Blockade in patients undergoing coronary artery bypass graft (CABG), evaluating if a beta blocker was received within the 24 hours prior to CABG surgery. For the outpatient setting, 2 measures were chosen, both for the heart failure (HF) population with LVSD: ACE Inhibitor or Angiotensin Receptor Blockers Therapy for LVSD and Beta-Blocker Therapy for LVSD. For transition of care, the SMEs selected 2 measures: Beta-Blocker Therapy (specifically with bisoprolol, carvedilol, or sustained-release metoprolol succinate) prescribed at discharge, in the LVSD patient, and Discharged on Statin Medication for ischemic stroke or TIA patients that are discharged on a statin therapy. Overall, there was a clear focus on heart failure—whether alone or in combination with acute myocardial infarction, stroke/TIA, and CABG—and the SME panel prioritized these measures due to the morbidity and mortality reductions demonstrated with appropriate use of these drugs in these populations. Glycemic control Eighteen existing endorsed measures relating to glycemic control were identified, comprising 2 inpatient measures and 16 outpatient measures. The SMEs opted to include both inpatient measures, as a pair of balanced measures that measure the incidence of hypoglycemic and hyperglycemic events. For the outpatient setting, the SMEs selected 2 measures: Statin Use in Persons with Diabetes and Comprehensive Diabetes Care: Hemoglobin A1c Poor Control (>9.0%)—test value greater than 9.0% or missing a result. The American Diabetes Association recommends a patient-centered approach to diabetes care and individualizing glycosylated hemoglobin (HbA1c) goals.22 The HbA1c measure includes tracking of consistent monitoring of HbA1c as well as of poorly controlled diabetes (HbA1c value exceeding 9%). The SMEs recommended this measure as it captures both monitoring and optimization of effective drug therapy. The American Diabetes Association also recommends that all patients with diabetes take a statin to reduce risk for heart disease.22 Pain management In the relatively short time since the publication of the first PAM article, issues related to pain management, use and abuse of opioids, and many related concerns have garnered national attention in the United States. Opioid stewardship is quickly becoming a focused commitment for many health systems. A wave of change in pain management is sweeping across the nation. Pharmacists are engaged in all aspects of medication management for pain. Highly trained and knowledgeable pain management pharmacists are often found in emergency departments, hospice care, oncology, trauma units, and ambulatory care, as well as serving in oversight and consulting roles for health systems. Interestingly, despite the aforementioned high degree of public and even regulatory activity related to opioids and pain management, quality measures targeting these issues have not fully progressed with many measures still under development. Of the 14 existing endorsed measures identified for pain management, 8 were focused on screening for and assessment of pain and 5 were related to medication use. Pharmacists can and do screen and assess pain status, but there were varying opinions as to whether pharmacists in most health systems would be accountable for ensuring this care. Therefore, the 5 measures that were directly related to medication use were selected. Three of these measures were developed by the PQA for identifying and reducing patient harm related to opioid use by targeting opioid dose (standardized to a total daily dose using morphine equivalent dosing) and prescribing (multiple pharmacies and/or prescribers) for non–cancer-related pain (Use of Opioids from Multiple Providers and at High Dosage in Persons Without Cancer, Use of Opioids at High Dosage in Persons Without Cancer, and Use of Opioids from Multiple Providers in Persons Without Cancer). These measures were designed for use by payers, health plans, and prescription drug plans rather than health systems. However, the SMEs believed the intent of the measures reflected health-systems issues related to pain management, especially in the ambulatory care setting. Another measure, Continuity of Pharmacotherapy for Opioid Use Disorder, was called out as a likely growing role for pharmacy personnel and health systems as more patients are referred to and receive care for opioid addiction and abuse. The SMEs also discussed other emerging pain management—related measures for future consideration. Two of the measures—newly developed by the PQA—include (1) Concurrent use of Opioids and Benzodiazepines and (2) Initial Opioid Prescribing. The third measure—still under development by CMS—is the Hospital Harm Measure for Naloxone Use, which assesses opioid-related adverse respiratory events in the hospital setting. The goal for this measure is to assess the rate at which naloxone is given for opioid-related adverse respiratory events or oversedation. This is not a new metric, but it is now being evaluated for more formal inclusion into several CMS quality programs. Behavioral health Decades’ worth of literature illustrates the positive impact pharmacists have as part of the behavioral healthcare team.23,24 Multiple studies demonstrate favorable outcomes in patient satisfaction, clinical markers, and costs when pharmacists are actively involved in behavioral health treatment.25-27 Despite this, there is an established need for consistency in the approach to measuring outcomes in studies of pharmacists improving behavioral healthcare. As a result of growing interest in reducing variability in patient care in this clinical area, a new behavioral health domain has been added to this edition of PAM. The SMEs in this area initially considered a list of 31 measures and concluded that while most of the available measures were adequate assessments of pharmacist activities to improve patient safety in the transition of care and outpatient areas of health systems, none were considered good PAM for the inpatient setting. Consequently, the SME panel only included 2 measures from the NQF database—1 transitional (HBIPS-5 Patients Discharged on Multiple Antipsychotic Medications with Appropriate Justification) and 1 outpatient metric (Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications). The outpatient measure could also be applied to the inpatient setting to address diabetes screening as part of recommended metabolic assessment for people with schizophrenia or bipolar disorder who are using antipsychotic medications. Public comments reinforced this and included suggestions for extending the screening to the pediatric population as well. Finding no other acceptable measures after reviewing the entirety of the NQF and NQMC database, the SME’s proposed quality measures currently in use in their respective organizations. Consensus was reached on checking for lithium monitoring (Patients Taking Lithium With No Recent Monitoring), a measure currently in use in the Veterans Health Administration healthcare system. Notably, the work group concluded that both of the measures they selected had universal applicability in the inpatient and outpatient care settings. Antimicrobial stewardship/infectious diseases Since the work group’s 2014 publication, several significant releases have promoted and advanced antimicrobial stewardship efforts. Key amongst these was the National Action Plan for Combating Antibiotic-Resistant Bacteria, which set aggressive goals to foster antimicrobial stewardship across a wide scope of healthcare settings.18 Release of the CDC Core Elements of Antibiotic Stewardship in the hospital, outpatient, and nursing home settings; and the Joint Commission’s Medication Management standard for hospitals, critical access hospitals, and nursing care centers (MM.09.01.01) complemented existing organizational and international guidelines which detail the valued role of pharmacists in antimicrobial stewardship programs (ASPs).28-31 These guidelines provide a framework to guide the implementation and optimization of ASPs in order to best improve patient outcomes. A review of the NQMC database revealed that neither the CDC Core Elements for Antibiotic Stewardship nor many of the specific recommendations contained within are endorsed by NQF. The work group acknowledged the importance of the Core Elements for all settings and chose to include it in the suite of recommendations, regardless of endorsement status. The CDC’s National Healthcare Safety Network’s Antimicrobial Use Measure (NQF-endorsed measure 2720) complements the Core Elements and facilitates the tracking, reporting, and benchmarking of antimicrobial use within ASPs and nationally. The work group felt adoption was important for pharmacy departments and ASPs to strive for since reporting is currently not universal. A review of the NQMC database identified 36 additional infectious diseases–related measures. These measures were developed by a wide variety of stakeholders and involve many syndrome-specific focuses in the inpatient and outpatient settings and during transitions of care. In general, limiting selections was difficult. Nearly all measures examined scored highly on the predefined criteria. The work group acknowledged the important role pharmacists play in promoting and conducting proper immunization of patients in all organized healthcare settings and in the community.32 An influenza immunization measure (Preventive Care and Screening: Influenza Immunization, NQF 0041) was selected for inclusion due to an ongoing performance gap, the morbidity and mortality associated with the disease, and low immunization rates overall despite topped out measures in the inpatient setting. The final work group selection was a carry-over from the previous work group (NQF 0058)—Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis. Bronchitis and other acute respiratory tract infections remain both associated with a high degree of unnecessary antibiotic prescribing and an important starting target disease state for ASPs in outpatient settings.30 Future steps Pharmacy departments should continue to drive quality measure monitoring and process improvement relating to quality, safety, adverse events, efficiency, cost and resource use, access, and other healthcare metrics within institutions, where possible, and strive to publish results of efforts to ascertain the effects of various staffing and practice models on performance. Opportunities for internal and external benchmarking of quality measures enable monitoring, reporting, and attributing medication management service value. In an effort to support implementation of these recommendations, the PAM Work Group enlisted expertise to develop pseudocodes for the selected measures. The pseudocodes outline specifications to create algorithms for internal benchmarking. To access the pseudocodes go to: https://www.ashp.org/Pharmacy-Practice/Resource-Centers/Quality-Improvement/Pharmacy-Accountability-Measures. The PAM Work Group recognizes the need to further refine the approach as described in this article. We anticipate that the work group’s future considerations will include, although not be limited too, determining the optimal quality measure database search methodology, incorporating commercial payer quality measure consideration, and including interdisciplinary review and discussion. Conclusion As the healthcare landscape continues to shift away from rewarding volume of patient care services to rewarding value and quality of patient care services, pharmacists have an opportunity to positively impact patient care outcomes while demonstrating value to both the patient and health systems. The national emphasis on quality measures has significantly increased the number of measures available. A process to review and select quality measures is described in this article, with the goal of simplifying health-system pharmacy departments’ efforts to identify important measures to influence. Acknowledgments The contributions of the following individuals are acknowledged: Anna Legreid Dopp, Pharm.D; Behavioral Health Subject Matter Experts Chris Paxos, Pharm.D., BCPP, BCPS, BCGP; Ericka L. Breden Crouse, Pharm.D., BCPP, CGP; Jonathan G Leung, Pharm.D., BCPS, BCPP; Jennifer Alastanos, Pharm.D., BCPP; Heather M. Mooney, Pharm.D., BCPS, BCPP; and Tera D. Moore, Pharm.D., BCPS, BCACP; Glycemic Control Subject Matter Experts Daniel M. Riche, Pharm.D., FCCP, BCPS, CDE, ASH-CHC, CLS; Jacqueline L. Olin, M.S., Pharm.D., BCPS, CDE, FASHP, FCCP; Amy Henneman, Pharm.D., BCACP, BCPS, CDE; Rachel Heilmann, Pharm.D., BCPS; Andrew B. Forest, Pharm D, BCPS; Pamela L. Stamm, Pharm.D., BCPS, BCACP, CDE, FASHP; and Adraine L. Lyles, Pharm.D., BCPS, CDE; Pain Management Subject Matter Experts Maria Foy, Pharm.D., BCPS, CPE; Suzanne Nesbit, Pharm.D., BCPS, CPE, FCCP; Lee Kral, Pharm.D., Mary Lynn McPherson, Pharm.D.; Courtenay Wilson, Pharm.D., BCPS, BCACP, CDE, CPP; and Amanda Locke, Pharm.D., BCACP; Antithrombotic/Cardiovascular Subject Matter Experts Toby Trujillo, Pharm.D., FCCP, FAHA, BCPS-AQ Cardiology; Allison Burnett, Pharm.D., CACP, Ph.C.; Snehal Bhatt, Pharm.D., BCPS, FASHP; Karen Berger, Pharm.D., BCPS, BCCCP; Deborah Caraballo-Colon, Pharm.D., Ph.C., BCPS-AQ Cardiology; Tuesdy Horner, Pharm.D., Ph.C.; and Michael Gulseth, Pharm.D., BCPS, FASHP; and Antimicrobial Stewardship Subject Matter Experts Curtis Collins, Pharm.D., M.S., BCPS, BCPS-AQ ID, FASHP; Edina Avdic, Pharm.D., M.B.A., BCPS-AQ ID; Sara Revolinski, Pharm.D., BCPS; Lucas Schulz, Pharm.D., BCPS-AQ ID; and Whitney Buckel, Pharm.D. Pseudocode developers: Nick Schutz, Pharm.D.; Janice M. Taylor, Pharm.D, BCPS. 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American Journal of Health-System Pharmacy – Oxford University Press

Published: Jun 3, 2019

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Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

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Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

Recommended quality measures for health-system pharmacy: 2019 update from the Pharmacy Accountability Measures Work Group

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